Summary
Introduction
The transition from laparoscopic to robot-assisted procedures leads to potential increase
in operative times and health care costs. Cumulative sum (CUSUM) analysis can objectively
study the learning curve to detect significant changes in operative timing and monitor
complication rates.
Objective
The objective of this study is to investigate the total and step-specific times for
pediatric robot-assisted pyeloplasty (RAP) to investigate the learning curve of a
single surgeon transitioning from laparoscopic to RAP.
Study design
This prospective cohort study included 50 consecutive RAP procedures performed since
the inception of our robotic program from June 2013 to January 2019. The CUSUM of
RAP total operative time (OT) was calculated to determine the breakpoints between
learning phases using piecewise linear regression. Cumulative-observed-minus-expected
failure chart with 80% and 95% reassurance boundary lines was constructed using 5%
acceptable and 10% unacceptable complication rates. Step-specific operative times
were prospectively recorded by an independent observer for port placement, dissection
and hitch stitch placement, pelvis dismemberment and spatulation, suturing and port
removal.
Results
Piecewise linear regression for OT identified breakpoints at case 13 and 29 suggesting
transition at these points between Learning to Proficiency, and Proficiency to Competency. The overall mean OT was 142.2 ± 46.0 min. There was a significant difference in
the mean OT between Learning (203.9 ± 35.3 min, the initial 13 cases), Proficiency (159.2 ± 18.6 min, the middle 16 cases), and Competency (126.6 ± 19.7 min, the last 21 cases) phases (p < 0.001). The complication rate for
RAP stabilized around the acceptable level of 5% up to case 41 before finalizing at
8% overall. The step-specific analysis suggested that suturing entered the Competency phase at case 27, with a 50% decrease in suturing time from Learning to Proficiency and Competency.
Discussion
Our study suggests that by case 30 a surgeon transitioning to RAP can achieve a significant
decrease in OT. Complication rates remained within acceptable limits throughout, indicating
that RAP can be safely adopted, even in low volume RAP centres. Suturing competency
seems to be a significant advantage of the robotic platform as suggested by early
significant decrease in suturing times noted between the Learning and Proficiency phases.
Conclusion
Graphical AbstractPiecewise linear regression of CUSUM (black dots) of robot assisted pyeloplasty (RAP)
operative times (blue) with breakpoints at case 12, 95% CI [11.6, 13.2] and case 29,
95% CI [27.5, 29.8], and an R2 value of 0.9875.
Keywords
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Article info
Publication history
Published online: August 11, 2022
Accepted:
July 24,
2022
Received in revised form:
June 16,
2022
Received:
February 17,
2022
Identification
Copyright
© 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
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- The opportunities and cautions of cumulative sum analysis in assessing learning curves in pediatric urologyJournal of Pediatric UrologyVol. 18Issue 6
- PreviewIn this issue of the Journal of Pediatric Urology, Stern et al. present on an experienced laparoscopic surgeon's experience in adopting the robotic-assisted platform for pediatric pyeloplasty [1]. This manuscript can be read at multiple levels. First, the authors nicely demonstrate both overall and task-specific learning curves for surgeons adapting the robotic technique. While the robotic platform has already saturated many marketplaces, this is relevant work for those areas where the surgical robot still represents an emerging opportunity.
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